Cardiology Flashcards
Name 3 ECG features seen in hypokalaemia?
U waves
Small/ absent/ inverted T waves
ST depression
What is the screening recommendation for AAA?
M >65 should all have one time screening
M > 55 with FHx should have one time screening
You suspect a patient has a leaking AAA, what is your first investigation?
Abdominal US
A patient has an abdominal US for a suspected leaking AAA, this is inconclusive, which is the next investigation to try?
CT
MRI aortography for surgical planning if CT unavailable
How would you manage an AAA which was 3.6cm?
3-4.4cm: Do annual ultrasound to monitor
4.5-5.4cm: Do 3 monthly ultrasound to monitor
>5.5cm: Consider surgery (and continue 3 monthly US until that time)
How would you manage an AAA which was 4.9cm?
3-4.4cm: Do annual ultrasound to monitor
4.5-5.4cm: Do 3 monthly ultrasound to monitor
>5.5cm: Consider surgery (and continue 3 monthly US until that time)
How would you manage an AAA which was 5.7cm?
3-4.4cm: Do annual ultrasound to monitor
4.5-5.4cm: Do 3 monthly ultrasound to monitor
>5.5cm: Consider surgery (and continue 3 monthly US until that time)
What are the two options for surgical management of AAA and when would each be used?
EVAR - If >1.2cm below renal arteries (65%)
Otherwise open surgery
A 62 year old woman is admitted to the medical ward with a 3 week history of fevers and lethargy. On examination you note a few splinter haemorrhages in the finger nails and a loud systolic murmur at the apex. Your consultant instructs you to take 3 sets of blood cultures and to arrange an ECHO.
Which organism (and type) is most likely to have grown?
Infective endocarditis
- staph aureus followed by strep viridans
What is the most common organism responsible for infective endocarditis for those with prosthetic valves?
Staph epidermidis
What is the most common organism responsible for infective endocarditis for IVD users?
Staph aureus
You are doing a medication review on a 79-year-old man. His current medications include aspirin, verapamil, allopurinol and co-codamol. Which one of the following is it most important to avoid prescribing concurrently?
Colchicine Digoxin Simvastatin Tramadol Atenolol
Atenolol
Beta-blockers combined with verapamil can potentially cause profound bradycardia and asystole.
A 58year old male is one month post STEMI. Which drugs should he be taking?
All post MI patients - CRABS (5)
Clopidegrel (or ticagrelor) Ramipril Aspirin B-blocker (Metoprolol/ biso/carvedi) Statins (Atorvastatin 80mg)
Following a stroke treated only with aspirin, what medication should a 59 year old gentlemen take following his discharge on D14?
All stroke patients should take Clopidogrel (lifelong) and a Statin (lifelong) as secondary prophylaxis
If allergic to Clopi, can take aspirin plus dipyridamole
A 52-year-old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis?
Subclavian steal syndrome characteristically presents with posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm.
An 85 year old gentlemen has ambulatory blood pressure monitoring. At what cut off would he be given antihypertensive medication?
Stage 2 (Clinic >160/100) (ABPM > 150/95)
Only treat stage one if under 80
An 65 year old gentlemen has ambulatory blood pressure monitoring. At what cut off would he be given antihypertensive medication?
Stage 1 (Clinic > 140/90) (ABPM > 135/85)
What is first line antihypertensive for:
a) White 50 yo F
b) Black 48 yo F
c) White 70 yo M
d) Black 64 yo M
a) ACEI
b) CCB
c) CCB
d) CCB
A 69-year-old man presents to his GP with progressively worsening breathlessness over a two month period. It is associated with a cough productive of white sputum which is worse at night. He has recently had some flu-like symptoms which lasted around two weeks and are now mostly resolving. When asked about night symptoms he says he is finding it harder to sleep lying down due to coughing and breathlessness and has been sleeping in his chair. He has a past medical history of chronic kidney disease, hypertension and angina as well as a 30-pack-year smoking history.
O/E pulse 71 bpm, BP 146/81 mmHg, temperature 36.7ºC and sats 93% on air. His chest expands equally and he has crackles audible at both bases and a widespread quiet wheeze. MLD?
Pulmonary oedema
- Orthopnea
- Clear sputum
- Hypoxia
- Bi-basal crackles
Pulmonary odema can also cause wheeze
During a cardiac arrest, whilst the defibrillator is charging, what should be done regarding chest compression’s?
Keep doing chest compression’s whilst defib is charging
During a VT/VF cardiac arrest, when should adrenaline and amiodarone been given?
1mg adrenaline and 300mg amiodarone IV once chest compressions have restarted after the THIRD shock.
Then every 3-5mins
During a pulseless/ asystole cardiac arrest what treatment should be initiated?
Asystole/pulseless-electrical activity should be treated with 2 minutes of CPR prior to reassessment of the rhythm
(Don’t shock)
A 25-year-old man with a history of Marfan’s disease presents with sudden onset shortness of breath and pleuritic chest pain. MLD?
Pneumothorax
A 67-year-old female with a history of chronic lymphocytic leukaemia presents with a 3 day history of burning pain in the right lower chest wall. Clinical examination is unremarkable. MLD?
Shingles
Pain and paraesthesia often proceeds the rash.
What are the first three steps in acute management of a narrow complex tachycardia?
1) Vasovagal manouvres
2) IV adenosine 6-12mg
3) Electrical cardioversion
Which two rhythms are shockable, when should a defibrilator be used?
VF or pulseless VT
Used defib as soon as possible
What advice should pregnant asthmatics be given regarding use of SABA’s and ICS’s?
Use as normal during pregnancy
A 29-year-old man presents complaining of central chest pain that occurs in the mornings upon waking up. Sometimes it comes on while playing computer games. He doesn’t seem to experience this pain while working out even though he describes his workouts as ‘intense and sweaty’. He does not have any risk factors for cardiovascular disease. His heart sounds are normal. MLD and explanation of disease?
Prinzmetal angina
Coronary artery vasospam - most episodes occur in the easy morning
A baby is delivered on the ward and on the neonatal examination a systolic heart murmur is heard. An echocardiogram shows right atrial hypertrophy and the septal and posterior leaflet of the tricuspid valve attached to the right ventricle. What is this condition most commonly known as?
Ebstein’s anomaly
Low tricuspid valve giving a large atrium and small ventricle
What clotting result is used to distinguish between haemophillia and von Willibrands?
Haemophillia = Normal bleed time vWD = Increased bleed time
Both have raised APTT and normal prothrombin time
What test should be used to monitor heparin levels?
APTT
What test should be used to monitor LMWH levels?
Anti-factor Xa (although routine monitoring not required)
What agent can be used to reverse heparin overdose?
Protamine sulphate
What is first line treatment for torsades de pointes? (3)
IV Magnesium Sulphate
- Also stop all QT prolonging drugs
- May need resus and defib if they go into VT
Note most torsades de pointes is fairly brief, however often reoccurs and can put px into VT
A patient with a tachycardia is unstable, what is the first line treatment?
Syncronised DC shocks
(AF, broad-complex and narrow complex tachycardias now all treated as above if unstable - i.e. hypotensive, MI, syncope, heart failure)
What is first line treatment for a regular broad complex tachycardia in a stable patient?
IV amiodarone (loading dose followed by 24-hr infusion)
- Could then consider lidnocaine or procainamide
What is first line treatment for an irregular broad complex tachycardia in a stable patient?
(Possible AF with bundle branch block)
- If onset <48hrs consider cardioversion
- Otherwise rate control (beta blocker or digoxin)
Don’t forget anticoagulation
What is the treatment for a regular narrow complex tachycardia in a stable patient?
1st: Vagal manoeuvres (sinus massage)
2nd: IV adenosine (6mg > 12mg)
3rd: Beta blockers to control rate
NB: 12mg adenosine CI in asthmatics
What is first line treatment for a irregular narrow complex tachycardia in a stable patient?
- If onset <48hrs consider cardioversion
- Otherwise rate control (beta blocker or digoxin)
Don’t forget anticoagulation
What are the conditions to provide drug treatment to someone with stage 1 hypertension?
Any of: < 80 End organ damage Diabetic/ renal/ CV disease QRisk2 > 20%
If none lifestyle advice only
What are the appropriate blood pressure targets for a patient with T2DM?
- If end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
- Otherwise < 140/80 mmHg
A 53-year-old man presents as he is worried about palpitations. These are described as fast and irregular and typically occur twice a day. They seem to be more common after drinking alcohol. There is no history of chest pain or syncope. Examination of his cardiovascular symptoms is normal with a pulse of 72/min and a blood pressure of 116/78 mmHg. Blood tests and a 12-lead ECG are unremarkable. What is the most appropriate next step in management?
Arrange a Holter monitor (24-hr ECG)
A 72-year-old female presents with irregular palpitations and feelings of light headedness for one month. Her pulse is regular at 84 beats per minute and her ECG is not indicative of any specific pathophysiology. On examination, you note a grade 3 diastolic murmur and when measuring her pulse you notice that her head nods subtly in time with her heart beat. MLD?
Aortic regurgitation
What are the three most common causes of an Ejection systolic murmur?
Aortic sclerosis Aortic stenosis (murmur radiates to carotids + narrow pulse pressure)
- Pulmonary stenosis
- ASD
- HOCM
What are the two most common causes of a pan systolic murmur?
Mitral regurgitation
VSD
What is the most common cause of an early diastolic murmur, what other characteristics are associated?
Aortic regurg
Louder on expiration and when leaning forward
Associated with collapsing pulse
What are the causes of a mid/ late diastolic murmur?
Mitral stenosis
Mitral valve prolapse
Coarctation of the aorta
What is the most common cause of a continuous murmur?
Patent ductus arteriosus
A 77-year-old woman is admitted to the ED with a three day history of lethargy and shortness-of-breath. She is confused and unable to give much useful history. On examination she is noted to be pale, pulse is irregular and around 160/min with a blood pressure of 80/56 mmHg. Her oxygen saturations are 96% on room air. An intravenous cannula is placed and bloods taken showing Hb 8.6. An ECG shows ST elevation. What’s your immediate management?
DC cardioversion
This patient is clearly unwell and hence we should following basic ALS - in this case the peri-arrest protocols. In simple terms if a patient has an arrhythmia and is showing signs of decompensation (hypotension, heart failure etc) then they should be immediately cardioverted. Whilst it is possible that an acute coronary syndrome has triggered everything both thrombolysis and percutaneous coronary intervention cannot be attempted given the tachycardia.
A 70-year-old man with an existing diagnosis of 5.0 cm abdominal aortic aneurysm and atrial fibrillation presents with acute onset abdominal pain radiating to his back. He is still actively bleeding and his observations show the following:
Blood pressure 90/40 mmHg
Heart rate 140 beats per minute
The decision is made to proceed with emergency surgery within the next thirty minutes What is the most appropriate management of his warfarin therapy?
Patients on warfarin undergoing emergency surgery - give four-factor prothrombin complex concentrate
A 7-year-old girl is brought to her GP by her mother. She is conscious but clearly struggling to breathe and has an urticarial rash on her body. The mother states that she saw another GP at the practice that morning and was prescribed a course of antibiotics for impetigo. The GP suspects she is having an anaphylactic reaction to the antibiotic. What dose of IM adrenaline should she administer?
300mcg
Children < 6 = 150mcg
Children 6-12 = 300mcg
Adults = 500mcg (1:1000)
(Always also give hydrocortisone and chloramphenimine)
What is a normal ejection fraction? (LVEF). In what common cardiomyopathies is the EF preserved and reduced?
Normal = >55%
Preserved: Hypertrophic
Reduced: Dilated
A 35-year-old Singaporean female attends a varicose vein pre operative clinic. On auscultation a mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the left lateral position. MLD?
Mitral stenosis
Classically rumbling mid-late diastolic murmur
You hear an ejection systolic murmur, what is the main way to differentiate between Aortic Stenosis and Aortic Sclerosis?
Aortic stenosis = Carotid radiation and LVH on ECG (big QRS’)
Aortic sclerosis = No carotid radiation, no ECG changes
How do you manage a major bleed in a patient on Warfarin?
(regardless of INR with major bleed)
1) Stop Warfarin
2) Give 5mg of IV vitamin K
3) Give prothrombin complex concentrate or FFP
How do you manage a minor bleed in a patient on Warfarin?
Stop warfarin
Give IV vitamin K 1-3mg (dose can be repeated after 24hrs if still over INR of 5)
Restart when INR < 5.0
How do you manage an INR of >8? (assuming no known bleeding)
Stop warfarin
Vit K orally 1-5mg
How do you manage an INR of 5-8? (assuming no known bleeding)
Withold 1-2 doses and recheck INR
A 75-year-old woman has suffered recurrent falls due to orthostatic hypotension. She has tried conservative measures such as taking in more fluid and salt. Her medications have been reviewed and some of her medications have been stopped. She has also tried wearing compression stockings. Nevertheless, she still suffers dizziness on standing up.
What is a possible medication option to reduce her symptoms?
Fludrocortisone and midodrine
What are the two most characteristic side effects of ACEI?
Cough
Hyperkalaemia
Renal disfunction
Angioedema
A 65-year-old man comes to see you as he has noticed that he has become increasingly short of breath and has to sleep with 3 or 4 pillows to help him breathe at night. He also reports feeling more breathless after climbing 1 flight of stairs. His past medical history includes high cholesterol and myocardial infarction.
On examination, you auscultate bibasal crepitations and note that his ankles appear swollen. Most appropriate investigation?
This patient has had a myocardial infarction in the past, therefore suspected heart failure should be investigated further with an echocardiogram within 2 weeks.
If the person has not had a previous myocardial infarction then, suspected heart failure should be investigated further with a B-type natriuretic peptide (BNP) blood test.
Also all should have an ECG
You suspect someone is having an event of ACS, what management is indicated prior to investigation?
GTN and 300mg aspirin
What is mortality of ACS at 6 months (if treated)?
15%
Anterior MI’s show most in which leads? Which artery is affected?
V1-V4
Left anterior decending
Inferior MI’s show most in which leads? Which artery is affected?
II, III, aVF
Right coronary
How do posterior MI’s present on an ECG?
Tall R waves in V1-V2
Possible ST depression in V1-V4 (reciprocal change)
What are the criteria for PCI in suspected ACS? (3 things on ECG and time criteria)
- ST elevation (2mm in anterior leads, 1mm in I,II,III,avF)
- Any new LBBB
- Posterior changes (ST depression + big R waves in V1-V3)
- Must be within 12 hours of symptom onset
You are seeing a patient in GP. They had cardiac sounding chest pain in the last (X) hours, what action do you take when X is:
a) Last 12 hours
b) 12-72 hours
c) >72 hours
a) Emergency hospital for same day assessment
b) Refer to medics for same day assessment
c) Perform ECG and trops before deciding further action
What is the most common complication of an MI within the first 48hours?
Pericarditis
Within 48 hours of an MI a patient presents with signs of LVF, dropping BP and a new murmur, what is most likely diagnosis?
Papillary muscle rupture
or ventricular septal rupture
What are the conditions for the Framingham criteria to diagnose heart failure? Name 4 of each criteria?
2 major or 2 maj + 1min
Major: PND, bilateral creps, neck vein distension, S3 gallop, cardiomegaly
Minor: Bilateral ankle odema, dyspnoea on exertion, HR > 120, nocturnal cough
How do you investigate a patient who meets the framingham criteria?
If previous MI: Echo in 2 weeks If no MI - do BNP - BNP < 100 (alternative diagnosis) - 100-400 = Echo in 6 weeks >400 = Echo in 2 weeks
Name the New York Heart Failure Classification
Stage I - No symptoms
Stage 2 - Slight limit of physical activity
Stage 3 - Exertion leads to symptoms
Stage 4 - Unable to undertake normal activity due to symptoms
Name the first four lines of heart failure management?
(Fursemide added for symptoms relief)
1) ACEI and BB
2) + Spironolactone
3) Add digoxin
4) Add hydralazine or isosorbide dinitrate
If symptoms require may need to consider CPAP
Which 2 BB’s can be used in heart failure?
Carvedilol or bisoprolol
Name 5 common features of cardiac tamponade?
SOB
Chest pain
Pulsus paradoxus (exaggerated decrease in BP on inspiration)
Features of pericarditis
Beck’s triad (muffled heart sounds, raised JVP, falling BP)
What is the classic presentation of pericarditis? (3)
Chest pain (dull or sharp or burning) - Worse on inspiration/ coughing - Better leaning forward and sitting up Pericardial friction rub (pathognomonic) Tachycardia, tachypnoea and fever
What is first line management for pericarditis?
Naproxen or other NSAID (14days)
- If lasting over one week do blood cultures and consider AB’s
Use Colchicine for 3 months to reduce risk of return
How do you manage cardiac tamponade (1)?
Pericardiocentesis (usually under echo guidance)
How is aortic stenosis managed? (3 points)
Asymptomatic = Monitor
Symptomatic = Valve replacement
Asymptomatic but valvular gradient >40mmHg = Consider replacement
Name 4 common side effects of beta blockers
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances, including nightmares
Name three containdications for use of beta blockers
Asthma
Concurrent verapamil use
Uncontrolled heart failure
A 56 year old male patient is diagnosed with angina. What is the first line treatment? (5)
LIFESTYLE ADVICE
+ Aspirin (75mg)
+ Atorvastatin (10-20mg)
Plus rescue GTN spray (PRN, use upto 3x in one go)
1st: Beta blocker or calcium channel blocker
In terms of anti-anginal therapy, what are the first three lines of treatment for stable angina?
1st: BB or CCB (verapamil or diltiazem)
2nd: BB and CCB (amlodipine/ nifedipine)
- Put to max dose before moving to (3)
3rd: Isosorbide mononitrate OR ivabradine OR nicorandil OR ranolazine
NB: Consider revascularisation before 3rd drug (i.e. CABG)
What advice should a patient with angina be given about sexual activity? (2)
If the patient can climb up and down two flights of stairs briskly without any symptoms of angina, sexual activity is unlikely to precipitate an episode of angina.
(if it does take GTN before intercourse)
- DO NOT combine GTN and viagra within a 24 hour period ever
How is HOCM inherited?
Autosomal dominant
You are working in a GP practice. Your next patient is a 27-year-old female who has just found out she is 6 weeks pregnant. She has a past medical history of familial hypercholesterolaemia, type 1 diabetes and asthma. She uses salbutamol and beclometason inhalers, regular insulin and takes atorvastatin. What should your next step in management be?
Stop statin
Pregnancy is a contraindication to statin therapy
Where do loop diuretics act?
Ascending loop of Henle